30 May 2008

I worked recently for one of my partners who had to deal with a family emergency. When I walked in at the appointed hour, the unit clerk saw me, and said in a clearly disappointed voice, "Oh it's you? I thought we were getting Dr Bob today..." I took it good-naturedly and gave her a little grief, but didn't give it any other thought.

Until the nurse in my designated area saw me, and said in the same tone, "Oh. Where's Dr Bob?" I explained that he was sick, and that I was working for him, and she was sort of quiet and left it at that. At that point I began to develop an inferiority complex.

The tech had the same reaction when she, too, realized there was no Dr Bob.

Finally, a fourth person saw me and said, "What are you doing here? The schedule said it was supposed to be-""Dr Bob, I know!" I snapped, "What am I, chopped liver?!" I had been under the impression that I was well-liked by the nursing staff, an impression that was rapidly evaporating.(Condescendingly) "Oh, you're fine. But every day when Dr Bob works, he brings in a big bag of candy for all of us.""Ah. I was not aware of that." Candy. So that's the ticket.

The other nurse came in at that point and saw me at the physician's desk, and exclaimed, "What? No Dr Bob? Damn. I wanted candy."

So now I know what to do to really get in the good graces of the nursing staff. I'm going to be stocking up on Costco-sized bags of candy. Then they will be disappointed when I'm not working.

27 May 2008

It's not your fault you guys are under-staffed and only have about two minutes per patient to ask them questions.

Well, it kind of is my fault. You see, I do the staffing for our ER. I hire the docs, and set the schedule, and figure out how many hours of staffing we will have every day. So, if we were under-staffed, hypothetically, it would be my fault.

Which got me to thinking, Are we under-staffing the ER? Not the first time I have contemplated the issue, and once again I concluded that no, we are not under-staffed. The way we staff is to volume, which is highly predictable.So we generally know how many patients are coming in, and when they are coming. I staff to about two patients per hour per doctor, which is somewhat more generous than other ERs do -- I know of some where three to four per hour is common; I don't think that's safe or sustainable. ACEP recommends about 2.25 patients per hour, though that number will vary dramatically depending on the acuity case mix, whether it's a teaching facility, and other factors. The graph above tells me how many new patients are presenting to triage every hour of the day; my job is to make sure that there are sufficient physician resources there at that time to actually care for those patients.

So why are we feeling like we are chronically short-staffed?

I think the big reason is demand-capacity mismatch. The capacity is more or less fixed in advance, and the demand fluctuates dramatically, which leads to chronic over- and under-staffed periods in the department.

The above graph is an average, and I staff to the average. From 10am-5pm I have 8 patients per hour presenting, so I have four doctors working. Sounds great, right? Except that real life isn't that predictable. If we have a busier than usual day, or if they come earlier than anticipated, then we are behind the eight-ball. I don't know the standard deviation, but half the days are going to be busier than average. Some of the variation is predictable: day-of-the-week is reliable (Sat, Sun, and Mon are the busiest days). Most of the variation is not, though. The month-to-month variation is highly unpredictable. Sometimes the flu season hits in December, sometimes in March; sometimes there's no noticeable spike in volume, and sometimes, as this year, there are 15% more patients than expected. The year-over-year growth is a huge factor, and is inherently unknowable.

Bearing in mind that I create the schedule two or three months in advance (yes, I could do it with shorter lead times, but that's really disruptive to people's lives), and that I am chasing a moving target, and that the fluctuations are so unpredictable, I think we do a good job. That does not, however, spare me from complaints from staff and patients when I happen to be there on a really busy day. Everybody wants more bodies. Of course, were I do respond by blindly increasing hours every time someone cornered me and complained that "we need more," then the proportion of days when we are so overstaffed that docs are sitting around drinking coffee and not making any money would increase, and salaries would go down. That is absolutely sure to generate a lot of complaints from the docs, and my experience is that when the money goes away, so do my employees, to greener pastures.

Finally, I might add to the anonymous commenter, that it's not just under-staffing that cannibalizes the time we get to spend with patients. At the optimal rate of two patients per hour, that's 30 minutes of my time per patient. During that time, in addition to the "time at the bedside," I'm going to do a lot of things -- review old records, create the new record, order tests and meds, track down the results of the tests, communicate with the nurses, communicate with consultants, communicate with family members or other historians, all while juggling the constant stream of interruptions that comes with taking care of eight to twelve patients at once. Given the complexity of modern medicine, the tremendous volume of data we create and digest, and the inherent inefficiency in the workflow, it's no surprise that of that 30 minutes we spend an average of less than ten minutes at the bedside.

25 May 2008

24 May 2008

Hillary suggests that she should remain in the race, just in case, you know, Obama is assassinated or something.

Well, of course that's not what she meant, but it's what she said. No take-backs on this one. Sorry, ma'am, once you invoke the specter of your opponent's potential violent death, you have officially jumped the shark, crossed the Rubicon, committed the mortal sin, and you need to be done. Now.

The woman is pathologic.

Olbermann says it better than ever I could. And summarizes the litany of other lies, distortions and deceptions the Clinton campaign has committed over the past five months.

To her credit, she did apologize. Sort of. To the Kennedys. Not to Obama, though, and a grudging half-apology at that, playing the "misunderstood victim" card.

21 May 2008

I hate taking care of old people. Don't get me wrong -- I have nothing against old people, and I always give my geriatric patients my full, undivided attention and the respect and compassion they deserve. But the problem is this: the ER is very busy, and I don't have a lot of time to spend with each patient. Wish I did, but I just don't. I have to be quick and efficient to keep ahead of the onslaught. So you remember way back in medical school, when you learned how to take a history? In my school, they really emphasized the need to need to ask a lot of open-ended questions and let the patient take the lead in providing the history.

Not in the ER. You get one open-ended question: What brought you to the ER today? And after that, it's a series of very directed questions: Where is the pain? How long? What type? Worse if you move? etc. These are the critical data points I need in figuring out where to go in evaluating your symptoms, and I acquire them quickly and accurately in the very limited time I have to spend with each patient.

But old people, Oh Jeebus save me, they are a trial. I don't know what happens to your brain when you hit seventy-five, but for some reason at that age you become incapable of giving a straight answer to a direct question. For example, an honest-to-god conversation I recently had:

Me: What time did your chest pain start?Granny: On the ferry.Me: So what time was that?Granny: Well, we were taking the ferry to the island, on account of my grandson was getting married. Now this is the grandson that I'm closest to, if you understand, because he's always been there for me when I needed him, and so of course I couldn't be expected to miss his wedding. I've got seven grandsons, three of them live out of state, and the others can't be bothered to call, let alone come over and help out. So when it was his big day, well, I just had to be there. Anyways, we were on the ferry, and there were five people in the car, two coming and two going, if you understand, and me. On account of that, I had to sit in the center seat in the car, and my legs were jammed up against my chest, because these foreign cars -- Japanese or Korean or some such -- they don't give you enough leg room in back, because they're all so short over there. And with my legs all jammed up tight against my chest, I just started feeling a little tight, you know?Me: (trying a different tact) Has the pain been constant since then, or does it come and go?Granny: I have the pain all the time, but only when I breathe, but it's worse when I go shopping, because they turn the air conditioning up so high in those stores, the cold air burns my lungs. It's not so bad when I ride in the little electric carts, but Safeway doesn't have the electric carts, so I usually shop at Albertson's....Me: (banging head on clipboard)

At the risk of overgeneralizing, I've seen younger patients who were evasive and tangential, but when I go and see an octogenarian, the likelihood is far higher that I'm going to be in there quite a while and come out without all the data that I really want. I can understand that when I do give the open-ended question that people will get circumstantial in their response, which is fine. But when I ask a simple, clear, direct question, is it too much to ask that I get a direct response? Apparently so.

Which is why I kind of cringe when I pick up the chart and see the age of the patient is over seventy. I've gotten used to it, though, since on some days my median patient age is over eighty; lotta nursing homes in our district.

I wasn't intending to get political with this post, but I was googling for my favorite Abe Simpson rant to illustrate the point, and I came across this, which made me laugh:

Update:

Just for the record, when time permits, I love to chat with the old folks. It's just that time doesn't usually permit.

16 May 2008

15 May 2008

There's a new player in the health finance reform game, bearing the ambitious name "Prometheus," so named for the Greek who challenged the omnipotence of Zeus and stole fire for mortal man. The Prometheus group hopes to challenge the dominant model of health care payment and "ignite reform." They are, it would seem, serious players, listing on their board the past president of the Leapfrog Group, the medical director for Toyota America, and the CMO of the Blue Cross Blue Shield Association, among others; they are funded through a Robert Wood Johnson grant.

The concept is not dissimilar to that of DRG (Diagnosis-related group) coding. If it is possible to predict the total cost of care for a given presentation, adjusted for severity, using best practices and as supported by clinical evidence, it makes sense to combine the payment into a single unified case rate. The money would then be divided among all participants in the patient's care as negotiated by the individual players. The idea is to promote coordination of care and close collaboration among the various members of the health care team.

Ostensibly.

Remember, though, that Prometheus' reward for bringing light to mankind was to be chained to a rock and have his liver eaten every day by a vulture.

I see this as an indirect way to further squeeze health care providers into providing services at lower cost. Call me cynical but I rather suspect that the Promethean case rates will fall short of what is currently being paid for care delivery. The idea of a single lump payment has superficial appeal, but its genius is to then let the the doctors, hospitals, medical device manufacturers, and other providers fight it out to see who gets the biggest slice of the pie. Classic "divide and conquer."

What many of these well-intentioned groups fail to realize is that controlling payment does not control costs. Look what has happened to hospitals with regard to orthopedic surgery: based on the DRG payment system, knee and hip replacements used to be major profit centers for hospitals; those profits were used to subsidize medical care which was under-compensated under the DRGs. Now, the rising cost of prosthetics has transformed the total joints into losses for the hospitals. The hospital gets paid less for the procedure than it actually costs to provide.

Does this mean that the hospitals can just stop doing total hips? No. Can they charge more? No. They just need to find other profit centers to cross-subsidize this new loss; spinal surgery seems to be very in vogue these days as the new cash cow.

So what will happen when the case rates under Prometheus start to squeeze? Predictably, the hospitals, being the bigger players, will keep the lion's share and the doctors will get squeezed. Even if the cost is equally shared, the effect will be to put further strain on hospitals' already thin margins and to further depress physician compensation.

13 May 2008

Paul Levy, TBTAM, and GruntDoc are having an interesting three-way (conversation!) about doctors and their negotiating skills, or lack thereof. It's worth a read -- interesting back-and-forth in the comments. My initial take is to agree that docs, by and large, are an embarrassing crowd when it come to the ability to negotiate effectively. I know that I was never taught in medical school about negotiating (and why would I be?), but once physicians start to segue into administrative careers or leadership positions, all of a sudden these mysterious skills become mission-critical, and woe unto the doctor who doesn't have or can't acquire these skills.

I meant to blog about that back in January when it happened, but never got around to it. It's always hard to read the tea leaves when you weren't in the room, but it sounded to me (and local rumor mill was) that the docs over-reached and put their demand forward too aggressively. This is in exactly the same vein as Paul Levy's statement that, faced with a doctor who begins with an ultimatum, his response would be, "Great, when are you leaving? We could use the office space."

I've been negotiating professionally for about five years now, mostly with insurance companies, but also with our hospitals and some other vendors. It really is an art. No two discussions are ever the same. I wish I could share some with you, but they do tend to be covered by NDAs once completed.

For my part, I had to learn through trial and error -- a lot of error, though fortunately none fatal. Also, my facility put on a series of workshops hosted by The Advisory Board on Physician leadership development. I can't say enough good things about educational offerings like those. It's almost like a mini-MBA for physicians, and the fact that it's sponsored (read: paid for) by the hospital helps a lot in building strong alliances between the medical staff leaders and hospital administration. The best seminar we ever had was on breakthrough negotiation. It contained a lot of material which seemed intuitively obvious, but maybe not for everybody, and helped to really formalize a way of thinking about how to negotiate.

The take-home point in this case is that when you are sitting at the table, brinksmanship and ultimatums rarely work, often backfire, and even if they do work tend to poison future discussions. I avoid them at all costs.

12 May 2008

Consumers are not in the position to make informed decisions regarding their health care. In many cases they have no options at all: once you are admitted to a hospital you are under the care of a slew of hospital-based physicians who are the ones "on service" at that time and if you don't like one or more of them, well, you're SOL. Worse, when you are really ill, your ability to make value-based health care decisions goes rapidly to zero: Which ER is this ambulance taking me to? Is it worth it for me to spend that extra day in the ICU? The surgeon standing next to my bed telling me I need an emergency operation seems too expensive -- is there a more reasonably-priced surgeon available? And maybe I don't need a quadruple bypass -- can you see if we can get away with a single-vessel job?

It's ludicrous.

Yet conservatives continue to contend that consumer-driven health care will provide a solution to the crisis in health care as costs continue to escalate. The claim is that consumers who bear significant out-of-pocket costs, or as they charmingly put it, consumers who have skin in the game, will make rational decisions regarding their health care which will lead to lower costs.Nothing could be further from the truth. Some "skin" might be a good thing -- Jeebus knows I've seen enough medicaid patients misuse the ER that I can see the undeniable value of a copay in driving good resource utilization. But the more "skin" in the game, the more likely patients are to defer necessary care, and the less control patients really have over the way the money is spent.

So when McCain and his henchmen extol the virtues of "market-based" solutions to the health care crisis, remember this and the intellectual bankruptcy of their misleading and dishonest health care plan.

The most wonderful thing I've seen today. I'm not sure if this is an ad for Apple, or for The Bird & The Bee. Either way, it's pleasant and slightly hypnotic, and someone clearly has way, way too much time on their hands.

09 May 2008

Maybe a contradiction in terms, but #4 on the list was Jon Stewart of The Daily Show. Journalism.org and the Pew Research Center take on the interesting question, "Is Jon Stewart a Journalist?" and comes up with an interesting answer: yes.

[TDS] draws on the news events of the day but picks selectively among them—heavily emphasizing national politics and ignoring other news events entirely. [...] The program also makes heavy use of news footage, often in a documentary way that employs archival video to show contrast and contradiction, even if the purpose is satirical rather than reportorial. At other times, the show also blends facts and fantasy in a way that no news program hopefully ever would. In addition, The Daily Show not only assumes, but even requires, previous and significant knowledge of the news on the part of viewers if they want to get the joke. [...] at times, The Daily Show aims at more than comedy. In its choice of topics, its use of news footage to deconstruct the manipulations by public figures and its tendency toward pointed satire over playing just for laughs, The Daily Show performs a function that is close to journalistic in nature—getting people to think critically about the public square.

As an example of why rational observers conclude TDS is something of a legitimate journalistic enterprise, I offer you this interview with Republican nominee John McCain:

I cannot recall any "news show" interview where McCain was asked point-blank how he intended to distance himself from the most unpopular president ever. He called him on the Hamas thing, too. Was it a soft-ball interview? Maybe a little; it was funny, too. But when you see Stewart's serious take on the important issues, expertly interweaved with light humor, it's hard not to come to the conclusion that this is a program which is genuinely interested in public discourse.

We all have our little tips and tricks that we have learned over the years, and this is one that really baffles me as to why it has never caught on more.

In residency, we used to have to put in central lines every single shift, often more than one per shift. This was ain an inner-city training program where IV drug use was endemic. So we devoted a lot of time and energy to getting good (and fast) at putting in lines. Now that I'm in the community, I wind up putting in lines a lot less often -- maybe once or twice a month, at that. But I did enough of them in residency that I'm still confident that I am good at them.

While I was training, I spent a lot of time struggling with the standard subclavian/internal jugular approaches. Not that I had complications or couldn't do them, but I was just never comfortable with those approaches. One day, an attending taught me the supraclavicular approach pictured above, and it was so simple, so fast and easy, so safe, that since then I have done almost 100% of my lines that way. Also, it's a great trick to have up your sleeve in the difficult line patient, because it's not commonly used. All the other line sites may be scarred down and inaccessible, but this one is usually still open, and you wind up looking like a hero, getting the line in the "impossible access" patient.

But it seems like almost nobody else uses this approach. Until recently it wasn't even in Robert & Hedges (the procedural bible for ER docs), and there's scant literature on the technique. Every so often I meet someone who does their lines the same way, and it's like meeting another member of some little secret society: "Really, you do these, too? Cool!" And we marvel at how clever we are and why doesn't everybody else do them?

So, I ask the docs reading this: of central lines you do (above the waist), what approach do you typically use and why?

05 May 2008

I've read a lot about Hillary and Obama's competing health care plans. With little fanfare this past week John McCain released his vision for solving America's health care crisis. I finally had a chance to sit down and really review McCain's plan for health care. The verdict? It's bad, about as bad as you would expect from this "moderate" "independent" "maverick" who somehow happens to embrace every last jot and tittle of the most extreme right-wing ideology. Really, short of an official policy of "screw it, you're all on your own," it's about as bad as you could ask for.

Now, understand, that nothing about this plan is particularly novel or innovative within conservative circles. The fundamental premises are:

Americans have too much insurance.

Because they have too much insurance, they are insulated from the true cost of health care.

Because American consumers do not individually bear the full cost of health care, they utilize too much health care, or health care that is overpriced.

By shifting the risk and cost of health care spending onto the American people, it is possible to limit wasteful health care spending.

Those ideologues who accept these premises as dogma will love McCain's health care plan. There are many features of the McCain plan which, derived from these principles, will predictably wreak havoc on the health care financing system as it currently exists in this country. While the consequences for consumers may be dire or even catastrophic, to the right wing, these are intentional and deliberate elements of their plan.

The main elements of McCainCare are:

Eliminate tax breaks for employer-purchased health care

Deregulate the insurance industry

Encourage Health Savings Acconuts (HSAs)

Create Guaranteed Access Plans (GAP) for high-risk individuals

Buzzwords (Quality, transparency, etc)

Now I'll cut McCain some slack on the "Buzzword" point. The longish segment of his plan which talks vaguely about increasing quality, chronic disease management, care coordination, IT development, price transparency, etc is pretty detail-free. Which is to be expected from a campaign's plan and is little different from the plans proposed on the left. Some of the proposals are bipartisan (chronic disease), some are pointless panders (drug reimportation) and some seem to be insoluble (price transparency). But it's not fair or relevant to devote a lot of attention to these relatively minor elements of the plan -- there's plenty not to like in the meat of the proposal as it is.

For example, the first substantial element of McCain's plan is to force Americans to bear the full cost of their insurance by delinking employment from insurance. Eliminating the tax break for employer-purchased health insurance would blow up the current system of health care financing. Employers, under this system, will drop their health care plans en masse, and employees will be left to purchase insurance on their own. While there will be some small tax credit given to families, the value of this credit ($5,000) is insufficient to cover the cost of traditional insurance even at today's prices ($12,000). More concerning, the rate of inflation for health care has outstripped inflation in general, and the tax credits are not indexed for inflation.

The consequence of this is that there would be strong incentive for consumers to purchase high-deductible catastrophic insurance policies and pay for low-level costs out of pocket. HSAs would help to some degree, for those wealthy enough to fund them and healthy enough not to spend more than the allowable amount you can put in an HSA. (Why am I not surprised that a conservative plan disproportionately favors the healthy and wealthy?) But for those unable to afford to fully fund a HSA, or those unlucky enough whose expenses exceed the amount funded, the out-of-pocket costs for their health care could be substantial. Remember that republicans view this as a feature, not a bug.

Now it's fair to point out that some of the plans on the left also decouple health care from employment. Wyden's plan does directly, and I believe both Obama's and Hillary's would encourage employers to stop paying directly for health care with a "play or pay" requirement for large employers. The difference is that the democratic-proposed plans reduce the role for employers while creating regulated insurance products which carefully pool risk across a large population.

McCain's plan, does the opposite by deregulating the insurance industry. That's not what they call it, of course. Rather, conservatives claim that state regulations are so onerous that they drive up the cost of insurance. Their proposal is to allow insurance products to be marketed across state lines. The consequence of this will be that large insurers will domicile themselves in whichever state has the least level of regulation and the most pliable legislature. States which have robust consumer protections in place -- guaranteed issue, prudent layperson legislation, bans on pre-existing condition exclusions, minimum benefit levels, etc -- will find that their insurance products are more expensive because they cover more benefits (and sicker people). The states which allow the most aggressive anti-consumer policies will have cheaper costs and the lowest common denominator will become the de facto national standard.

So when millions of individuals are forced into purchasing individual insurance policies in this deregulated market, those who are young and healthy will not have difficulty finding affordable policies which cover their minimal health maintenance needs. But those who are older or have pre-existing conditions will find themselves uninsurable in this new "free" market, and will have to seek out some alternative funding for their health care. McCain envisions GAP plans as insurers of last resort for these people. However, due to a phenomenon known as "adverse selection," these plans will cover all of the sickest consumers and the cost of coverage must as a result be exorbitantly high. McCain's plan states that premiums will be "reasonable," but does not specify how: whether the GAP plans will be subsidized by tax dollars or whether "reasonable" might in actuality mean "exorbitantly expensive." Unless the GAP plans are very heavily subsidized, the actual cost of insuring these consumers must be very high, and absent subsidies GAP plans would need to pass along the full cost of the health care to the insured, resulting in ruinous and unaffordable premium costs. Large subsidies would be difficult to reconcile with McCain's pledge to further cut taxes.

Although McCain offers assistance to Americans "below a certain income level," it is not clear what, if anything, his plan would do to cover the uninsured. I suppose there are some young and healthy people out there who do not currently purchase insurance who might buy a cheap catastrophic policy -- but those policies already exist, and if not so motivated to buy them now, McCain's plan does nothing to change that. The working people who make too much to qualify for medicaid but too little to afford insurance still fall through the cracks, unless McCain's assistance is more generous than would be characteristic of republican policies in general. Call me cynical, but I've seen nothing to suggest such a thing.

The other ostensible features of McCain's plan are illusory, all smoke and mirrors. They claim that consumer-directed health care will create competition and lower costs, but the fact remains that consumers are more likely to defer needed care when they are forced to pay the cost, and skipping preventative care is likely to increase future costs. Neither are consumers in an information-based position to accurately assess the price/value ratio of many medical procedures, nor are they entirely rational players when it comes to health care (witness the growing popularity of full-body CT scans if you need proof).

The "competition" canard is particularly deceptive -- that insurers in a national market would compete the cost of premiums down. There already is relentless competition in every state, and almost all major insurers -- Aetna, UnitedHealth, Cigna, BC/BS, all currently have a presence in every state. Opening the markets would simply strip essential consumer protections from the majority of plans. While there would be competition for desirable patients -- the young and healthy -- experience has shown that insurers are not to be trusted, and will seize on the most minimal pre-existing condition to jack up premiums beyond any justifiable measure, and drop patients whose coverage turns out to be unprofitable.

Ultimately, this is an irrelevant, dead-letter proposal, which explains the lack of detail and effort put into its development, because even if McCain were to be elected in November (shudder), there is almost certainly going to be a Democratic Congress, and it is Congress that would be writing the legislation to reform health care. It is, however, a useful insight into McCain's governing philosophy and priorities: rigid orthodoxy along ultra-conservative lines; ideology placed above pragmatism; rampant deregulation; giveaways to industry, in this case the insurance industry; favoritism of the wealthy over the middle class; and continuation of the shift of risk and cost onto the shoulders of consumers.

I am, it is sad to say, a chronically late individual. This is not the greatest trait to have in an ER doc; the single most important thing about being the ER doc is you have to be there. In training, after a few weeks of enduring withering stares from the chief as I strolled in late, I learned to be on time to work.

More or less.

The other day, I made a special effort to be a little early to work, and with a minor traffic delay I walked in right on time, exactly to the minute that I was supposed to be there. I greeted my two partners who were at the physicians' desk filling out their charts. They looked at the clock, and one of them groaned and, wordlessly, pulled out ten dollars and gave it to the other.

"You're killing me," he complained, "I had you down for five after."

So the moral of the story is that when people start taking bets on how late you are going to be, it is time to change your ways with regard to getting to work on time.

04 May 2008

Funny story -- the Democrats ran an ad, the entire substance of which is John McCain in his own words:

The Republican National Committee is suing to keep it off the air, calling it "false and defamatory."

I'm not a lawyer, but can it possibly be defamatory to simply air McCain's own, unscripted views?

(Note: McCain and his apologists are now claiming that he didn't mean he wants to stay fighting in Iraq for a hundred years, but to stay in another, hypothetical Iraq, where there's no fighting and we're basically just hanging out and drinking lemonade. I agree -- I'd like to find that Irag and go there, because it beats the hell out of the quagmire we're in right now.)

03 May 2008

Letting children bask in the reflected glory of an iPhone apparently hypnotizes and soothes their nerves enough that it is possible to perform surgery without anesthesia. At least that was the gist I got from this overly messianic Gizmodo article.

As if! When I am blessed enough to carry one of those holy articles, there's no way I will let horrible, grubby children touch it. Not even mine.

Fake Steve Jobs weighs in:Please be responsible. Do not use the hypnotic power of iPhone to knock people out in places that are not appropriate. Like on the subway, or while sitting in traffic, or in restaurants, or on dates. And yes, Woz, I'm talking to you. Freak.

01 May 2008

There are a few things in the field of Emergency Medicine that are unsavory. To put it mildly. Not long ago, I saw a homeless patient who had been living on the street for a long time. He was a heavy alcoholic, but to my great surprise, despite being a long-time undomiciled resident, had almost never been to the ER before.

He had run out of money and stopped drinking, so, predictably, he had a withdrawal seizure, which was witnessed and 911 was called and brought him to us.

I have a lot of experience taking care of homeless people. It's part of the job. I am very familiar with the obligate squalor that comes with living on the street and the attendant lack of hygiene. This guy was beyond the pale. It's very hard to explain the degree of filth this guy had. His several layers of clothes were all encrusted with god knows how many years of bodily fluids, old beer, vomitus, and general dirt. His long hair stood straight out from his head as if he had received an electric shock, and his beard was matted and fouled with small bits of food. The smell was horrible, and I was grateful that his presenting complaint did not require a more intimate examination. I was in and out of that room in no time flat.

Except that he decided to seize again. Oh well, back in I go, medicate him with an anti-seizure drug, and re-assess. While standing there waiting to see if he would seize again after the meds, I noticed that he had these little white bits of food in his beard, but also in his hair, which I thought odd. On closer examination, I realized that the little white bits were moving. They were bugs, though the type I cannot identify. Some were big and had wings, so they were not lice or maggots or fleas. Some were clearly lice. There were lots of them, lots and lots of bugs crawling all through his hair and in and out of his clothes.

(I'm itching now just writing this post. I'll bet in a minute or two you, reader, will involuntarily start to scratch as well.)

The patient was pretty sleepy after the medicine, so we left him there for observation to see how he would do. As I left the room I jokingly commented that he needed a "stat delousing."

Not long after, I noticed his nurse and a tech standing outside the door putting on protective gear. Lots of it. Gowns, hairnets, scrub pants over their work pants, masks, face shields, gloves. What we call the "full body condom." They went into the room and they stripped the patient naked. Disposing of his clothes, they shaved off his beard and all his hair, and scrubbed him head to toe with soap and lots of water. They covered his body with whatever medicated anti-lice lotion the hospital happened to stock, and they fitted him with new, clean and warm clothing from the donation box.

I was in awe. The "yuck factor" of this patient was off the scale, even viewed at a distance, and they spent an hour or more cleaning and delousing him, all on their own initiative. What they had to endure to accomplish that task was beyond my intestinal fortitude.

When finally they were done, I made it a point to express my admiration and gratitude in the most direct way I could -- I went down to the hospital Starbuck's and bought them their favorite drinks (white chocolate mochas). And I wrote an email to the hospital CEO and Chief Nursing Officer, praising their dedication to duty. Just incredible.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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